Less treatment regret with SBRT, and when patients are fully informed

There is growing recognition that the patient’s satisfaction or regret with his treatment decision is more than just a matter of whether he is happy with the oncological outcome. Satisfaction/regret is the product of many variables, including how well he understood his options, his interactions with his doctors, the side effects he suffered and when he suffered them, his expectations about the side effects of treatment, and cultural factors. Providing greater value for the patient was the subject of a recent commentary and survey from the Sitemaster.

Shaverdian et al. explored the issue of treatment therapy (SBRT), and high-dose-rate brachytherapy (HDR-BT). Questionnaires were sent to 329 consecutive low-risk or favorable intermediate-risk patients treated from 2008 to 2014 with at least 1 year of post-treatment follow-up. There was a high response rate of 86 percent. The number of responses were:

  • IMRT — 74 patients
  • SBRT — 108 patients
  • HDR-BT  — 94 patients

Patient characteristics were similar across treatments. The only significant differences were:

  • HDR patients were a median of 5 years younger
  • IMRT patients were disproportionately African-American and Asian-American
  • Length of follow-up was longer for IMRT patients
  • HDR patients were more likely to be taking medication for erectile dysfunction.

Decision-making process

Patients who chose IMRT spent less time making their decision. The percentages that spent less than a month making their decision were:

  • IMRT — 47 percent
  • SBRT — 31 percent
  • HDR-BT —  12 percent

Although most patients felt they had learned enough about the treatment options before making their decision, those who chose IMRT were least likely to say so:

  • IMRT — 83 percent
  • SBRT — 91 percent
  • HDR-BT — 86 percent

In addition, 11 percent of the IMRT patients wished they had learned more about active surveillance.

There was widespread agreement that they had worked mutually with their doctors to arrive at a decision.

  • IMRT — 85 percent
  • SBRT — 91 percent
  • HDR-BT — 84 percent

Treatment regret

The percentages of patients who felt that they would have been better off with a different choice was least for SBRT:

  • IMRT — 19 percent
  • SBRT — 5 percent
  • HDR — 18 percent

This rate of treatment regret for IMRT and HDR is similar to the rate expressed for surgery (see this link).

Of those who expressed treatment regret, the biggest reason for it (36 percent) was because they could have had better sexual function; 72 percent of those with treatment regret would have chosen active surveillance if they had it to do over again.

After correcting for patient characteristics, the factor most associated with treatment regret was whether they had learned enough about other treatments. Those with treatment regret were 53 times as likely (i.e., odds ratio = 53) to say that they had not learned enough. The next biggest factor predicting treatment regret was whether the long-term side effects were worse than expected (odds ratio = 42). Expectations and the disappointment of those expectations have a large impact on treatment regret. Those who chose IMRT were 11 times more likely to have treatment regret than those who chose SBRT, and those choosing HDR-BT were seven times more likely to experience treatment regret compared to SBRT. The table below shows the odds ratios for all statistically significant factors:


While IMRT was the highest-cost treatment, it also gave the lowest perceived value to the patient. Conversely, SBRT, the lowest-cost treatment, provided patients with the highest perceived value. To increase value to patients, doctors must assure that patients are fully informed about all their treatment options, and the side effects that they may reasonably expect. Patients should be encouraged to take their time investigating options, especially active surveillance.

All patients in this study were treated at UCLA, which has a policy of fully informing patients of all their options and expected outcomes. It is impossible to entirely separate the effect of superior patient counseling on the part of the physician from superior treatment outcomes as the reasons for increased patient satisfaction. Perhaps if this questionnaire were used across multiple institutions those effects could be distinguished.

Also, because UCLA is a nationally renowned tertiary care center, these results are not applicable to what goes on in the community setting. If expanded, we would like to see comparisons with other treatment modalities: surgery (robotic and open), low-dose-rate brachytherapy, active surveillance, proton beam radiation therapy, hypofractionated IMRT, and focal ablation therapies. It would also be instructive to compare the value attached to adjuvant treatment modalities (e.g., brachy boost therapy and hormone therapy) given to patients with more advanced disease and in the salvage setting. It is a good start, however, and provides a validated questionnaire by which treatment centers can assess their performance and set goals for improvement. We would love to see this “report card” expanded nationally.

Editorial note: This commentary was written by Allen Edel for The “New” Prostate Cancer InfoLink. Allen thanks Dr. Christopher King of UCLA for providing him with the full text of the relevant article for review.



One Response

  1. Your sitemaster freely admits that he is absolutely delighted to see this comprehensive report on patients’ evaluations of their degree of satisfaction/regret with differing types of radiotherapy in the treatment of prostate cancer. In some ways, I believe that this paper has the potential — over time — be as influential on the management of prostate cancer as were Walsh’s early papers on the role of nerve-sparing surgery in the 1980s.

    I say this not because of the fact that the paper shows that one form of radiation therapy appears (at least in this study) to be better accepted than another. We probably have more to learn about why that may be the case. But what this paper very clearly shows is: (a) that there are good ways to measure and compare patients’ relative levels of satisfaction/regret; (b) that these ways to assess satisfaction/regret can incorporate individual patient’s opinions on how well they felt informed by their individual physicians at this critical juncture in the decision-making process; and, perhaps most importantly, (c) that such data can be used by relevant institutions to advise individual physicians whether they are meeting reasonable and acceptable standards in informing their patients about the risks and benefits of differing types of treatment and then actually delivering the results that they claim.

    The fact that we are now able to do this, and the willingness of the radiation oncology community to publish a paper like this in a premier radiation oncology journal (as opposed to in a journal where it would rarely be read by the actual treating community), are major, major steps forward in acknowledgement and acceptance of the idea that patients are entitled to more than “treatment” for their prostate cancer (or almost any other forms of cancer) and that the medical community could and should, in the future, build evaluation of such outcomes into as many studies of the effectiveness and safety of treatments as possible … most particularly when it comes to comparative outcomes of differing types of treatment.

    One wonders whether it would be possible to use such a process to evaluate the satisfaction of the nearly 2,000 patients who participated in the ProtecT study in the UK, which would provide some interesting insights into the perceptions of the patients regarding the choices of surgery, radiation therapy, and active surveillance in that study.

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